Sorry for the novel! I have an odd case that I wanted some input on.
Patient History: 66 year old female with CMML. A Pos, with a negative antibody screen, no history of clinically significant antibodies. Has HLA antibodies that have never been detected in our IgG antibody screen testing, but cause her to be refractory to random platelet transfusions. Has been getting HLA-matched platelets. She has received 9 RBCs and 24 apheresis PLTs over the month of September.
Transfusion Reaction: The patient received 1 O Pos HLA-matched apheresis platelet (Anti-A titer <1:200) on 8/29/16 at 1100, and 1 electronically compatible A Pos PCLR right after the platelet was done infusing. After the RBC infusion, the patient developed chills/rigors, flushing, and felt tired and "out of it" according to the RN. Her temperature had increased >2 degrees F, so a transfusion reaction investigation was initiated.
Clerical Check OK Gram stain on both the RBC and PLT were negative. Cultures from both are still pending. Post-Rxn Sample: ABO/Rh = A Pos Poly (IgG/C3) DAT = 1+ Positive Mono IgG DAT = 2+ Positive Mono C3 DAT = 1+ Positive Aby Screen = Negative Plasma color = slightly darker than Pre-Rxn sample, but not visably hemolyzed Pre-Rxn Sample: Poly (IgG/C3) DAT = Negative Aby Screen = Negative Gel/AHG XM of transfused RBC with Pre- and Post-Rxn samples = Negative/Compatible RBC unit DAT = Negative So, we obviously decided to perform an eluate on the post-reaction sample. The eluate was tested against screen cells, A1 cells, B cells, and panel cells, and showed no reactivity. Questioning the original eluate, we performed an eluate on a new post-reaction sample the next morning (8/30), and got the same results.
We decided to try running both eluates against the transfused RBC and the patient's own cells from the pre-reaction (DAT negative) sample. The eluate did not react with the transfused RBC, but reacted 1+ with the patient's Pre-Rxn sample.
How the heck do I explain this!?
As I'm sure everyone else is doing, we are trying to find ways to cut costs. We are a medium sized hospital (<400 beds) in a rural setting without a trauma designation. Annually, I look at supplier contracts including reference lab testing. We currently do our own antigen typing and primary and secondary antibody ID panels but do not keep an enzyme panel nor do we do adsorptions, although we do perform elutions. Most of my staff are generalists and at least half of them are MLT's.
I am curious to know the size of your institution and how much, if any, of your serology you send to a reference lab. We are seeing more complex patients (in volume, not necessarily complexity) and I am considering bringing in enzymes and adsorptions. Please give me your thoughts. Thanks!
Doing an informal survey for anyone willing to contribute. If you're willing to respond but not in the thread itself, please feel free to message me.
When do you perform an elution? (e.g. all positive DATs, all positive DATS within 3 months of transfusion, IgG positive only) What method is utilized for the elution? What method is utilized for testing the eluate? How is the eluate tested? (e.g. screening cells, full panel, specially selected cells) Feel free to mention any special notes/criteria for which I may not have though to ask. Thanks in advance to all participants!
I feel like I was just struck by a blinding flash of the obvious with a little dash of "we've always done it that way."
When we do an elution, we perform an antibody screen with the eluate and the last wash, and an antibody ID panel for positives (or selected cells in rare cases when a lower incidence antibody is considered).
86860 is to cover the process that makes the elution; are we completely failing to charge for the additional antibody screen and antibody ID?
By Mabel Adams
Does anyone have any procedures that they can share for making up student specimens, either spiking plasma samples with antibodies but even more so, making up specimens for doing eluates? If there are some on this site already, sorry for the repeat, but I can't find them.